Time to bust common osteoarthritis myths

Abstract

Several common beliefs about osteoarthritis held by people living with the condition and some clinicians are discordant with current evidence and can hinder effective management. Therefore, providing information about the disease and its mechanisms could lead to better management of people with osteoarthritis. This paper addresses the seven most common myths surrounding osteoarthritis relating to its causative factors, pathology, assessment and management. We present the evidence to refute these misconceptions and argue that physiotherapists are in an ideal position to provide education to people with osteoarthritis. Ultimately, physiotherapists can play a central role in the provision of care for people with osteoarthritis.

Full text

18 | NEW ZEALAND JOURNAL OF PHYSIOTHERAPY
SCHOLARLY PAPER
Time to bust common osteoarthritis myths
DanielW.O’BrienPhD
Senior Lecturer, Physiotherapy Department, School of Clinical Sciences, Auckland University of Technology, Auckland, New Zealand
CathyM.ChapplePhD
Senior Lecturer, School of Physiotherapy, University of Otago, Dunedin, New Zealand
JenniferN.BaldwinPhD
Post-Doctoral Fellow, School of Clinical Sciences, Auckland University of Technology, Auckland, New Zealand
PeterJ.LarmerDHSc
Head of School, School of Clinical Sciences, Auckland University of Technology, Auckland, New Zealand
ABSTRACT
Several common beliefs about osteoarthritis held by people living with the condition and some clinicians are discordant with
current evidence and can hinder effective management. Therefore, providing information about the disease and its mechanisms
could lead to better management of people with osteoarthritis. This paper addresses the seven most common myths surrounding
osteoarthritis relating to its causative factors, pathology, assessment and management. We present the evidence to refute these
misconceptions and argue that physiotherapists are in an ideal position to provide education to people with osteoarthritis. Ultimately,
physiotherapists can play a central role in the provision of care for people with osteoarthritis.
O’Brien, D. W., Chapple, C. M., Baldwin, J. N., & Larmer, P. J. (2019). Time to bust common osteoarthritis myths. New
Zealand Journal of Physiotherapy, 47(1), 18-24. https://doi.org/10.15619/NZJP/47.1.03
Key Words: Osteoarthritis, Beliefs, Attitudes, Treatment, Misconceptions
INTRODUCTION
Osteoarthritis is the most common form of arthritis and,
typically, affects the joints of the knees, hips, spine and hands
(Hochberg, Silman, Smolen, Weinblatt, & Weisman, 2015;
Palazzo, Nguyen, Lefevre-Colau, Rannou, & Poiraudeau, 2016).
People with osteoarthritis often experience pain, joint stiffness
and weakness; this can affect their mobility, function, ability to
work, mental well-being and independence (Hall et al., 2008;
Hawker et al., 2010, 2011). Approximately 670,000 New
Zealanders live with some form of arthritis, of which 56% of
these people have osteoarthritis. Furthermore, prevalence is
expected to reach 1 million by 2040 due to projected increases
in the age of the population and the growing obesity rate,
factors known to affect the development of osteoarthritis
(Access Economics, 2018; Cross et al., 2014; Palazzo et al.,
2016). The total estimated cost of arthritis in New Zealand is
$12.2 billion per year, including $993 million in health sector
costs, $1.2 billion in lost productivity and $1.6 billion in formal
and informal care (Access Economics, 2018).
There is currently no cure for osteoarthritis, and unlike other
forms of arthritis, there are no disease-modifying drugs with
proven efcacy available for the condition. The focus of recent
research has been on the maintenance of physical function,
symptom reduction and limiting disease progression (Hochberg
et al., 2015). Exhausting all conservative treatment options is
encouraged before more invasive interventions are employed
(Hunter, 2017; Van Manen, Nace, & Mont, 2012; Zhang et al.,
2008). Current clinical guidelines recommend the use of non-
pharmacological treatments, such as lifestyle change, weight
loss, exercise and manual therapy (non-pharmacological), before
considering medication or surgery (Bennell, 2013; Bennell &
Hinman, 2011; Dean & Gormsen Hansen, 2012; Fransen et
al., 2015; Merashly & Uthman, 2012; Van Manen et al., 2012;
Zhang et al., 2008). The National Institute for Health and Care
Excellence (NICE) Osteoarthritis Guidelines (2014) advocate for a
staged progressive model of clinical management, which shows
a progression from non-pharmacological to pharmacological
to surgical management of osteoarthritis. However, non-
pharmacological treatments are underutilised, and while failed
conservative management is a prerequisite for surgery, some
people are offered joint replacement surgery without having
completed appropriate conservative management (Brand et
al., 2014; Hunter, 2011; Hunter & Lo, 2009). The continued
focus by some clinicians on the provision of pharmaceutical and
surgical treatment options has prompted some researchers to
publish editorials arguing that most people with hip and knee
osteoarthritis in high-income countries receive substandard
care (Hunter, 2011, 2017; Hunter & Lo, 2009; Hunter, Neogi,
& Hochberg, 2011). Additionally, it has been suggested that
some clinicians are guilty of benign neglect because they take
a fatalistic view of osteoarthritis or see conservative treatment
as ineffective or too complicated for their patients (Brand et al.,
2014; Poitras et al., 2010).
Despite the considerable amount of research detailing best
practice management for osteoarthritis, many high-income
countries, including New Zealand, have been slow to adopt
these recommendations (Baldwin, Briggs, Bagg, & Larmer, 2017;
Bennell, Dobson, & Hinman, 2014; Hunter, 2017). This delay
has been attributed, in part, to some of the common myths
about the disease (Hunter, 2017). In particular, myths about
causative factors, the pathology, assessment and management

NEW ZEALAND JOURNAL OF PHYSIOTHERAPY | 19
of osteoarthritis abound. This paper aims to challenge the
myths commonly attributed to osteoarthritis that limit effective
treatment; outline best clinical practice; and encourage
physiotherapists to engage with people with osteoarthritis.
MYTHS COMMONLY ATTRIBUTED TO OSTEOARTHRITIS
Myth 1: Osteoarthritis is just an old person’s disease
It is true that the likelihood of having osteoarthritis increases
with age, but it is incorrect to claim that it is an “old person’s
disease” as hip and knee osteoarthritis can also affect younger
people (Ackerman, Kemp, Crossley, Culvenor, & Hinman, 2017).
Ackerman et al. (2015) demonstrated the considerable personal
burden experienced by younger people (20 to 55 years) with
lower limb osteoarthritis, and recommended the provision of
targeted services for people in this age group. Furthermore,
younger aged people warrant additional attention to reduce the
development of comorbidities which may further compromise
their well-being (Skou, Pedersen, Abbott, Patterson, & Barton,
2018). Hence, it is false to solely attribute the development of
the disease to increasing age as its aetiology is multi-factorial
(Hochberg et al., 2015). The exact association between
osteoarthritis and increasing age is complex and not currently
fully comprehended (Hochberg et al., 2015). Increasing age
can lead to thinning and fracture of the cartilage covering the
articular surfaces of the joints. These changes can result in joint
laxity, predisposing the joint to increased shear stresses and
injury, promoting progression of the disease (Cross et al., 2014;
Hochberg et al., 2015).
However, many factors other than age are associated with
an increased chance of developing osteoarthritis. These
include gender, obesity, genetics, joint structure, a history of
injury and occupation (Palazzo et al., 2016). Osteoarthritis is
characteristically more prevalent in women than men, with
an odds ratio of 1.6 (95% condence interval [CI] 1.4-2.1)
(Silverwood et al., 2015). The reason for this is linked to
differences in hormones, joint alignment, cartilage volume
and muscle strength (Cross et al., 2014). People who are
obese are 2.7 times more likely (95% CI 2.2-3.3) to have knee
osteoarthritis than people who are not obese (Silverwood et al.,
2015). Increased body weight is believed to cause additional
joint loading and damage (Bliddal, Leeds, & Christensen, 2014)
as well as to contribute to systemic inammation (Piva et al.,
2015). Previous hip or knee joint injury is strongly associated
with the development of osteoarthritis (Hochberg et al., 2015).
Rupture of the anterior cruciate ligament predictably leads
to the development of knee osteoarthritis in 13% of people
within 10 to 15 years of the injury, and this rate increases
to between 20 and 40% if the injury also includes damage
to other ligaments, bone or cartilage (Palazzo et al., 2016).
Poor joint alignment is associated with the development of
osteoarthritis and more strongly associated with progression
of the disease (Cerejo et al., 2002; Sharma et al., 2010). In the
hip, joint dysplasia can commonly lead to the early development
of osteoarthritic changes (Jacobsen & Sonne-Holm, 2005).
Additionally, excessive occupational loads have been linked
to increased risk of disease development, especially if the job
or occupation requires a lot of kneeling, squatting, lifting or
climbing (Palmer, 2012).
Practice point myth 1: Osteoarthritis can affect younger people
and should be considered as a provisional diagnosis where there
are appropriate signs and symptoms.
Myth 2: Osteoarthritis is just joint wear and tear
Osteoarthritis is commonly typied by structural cartilage
changes. However, there are also changes in the muscles,
bone and synovial tissue at the joint. Hence, it may be best to
conceptualise osteoarthritis as a syndrome or a collection of
signs and symptoms. The pathology of osteoarthritis is multi-
faceted, and many different factors contribute to the joint
degeneration that occurs (Dell’Isola, Allan, Smith, Marreiros,
& Steultjens, 2016). These include biomechanical overload,
structural changes of the cartilage, metabolic mechanisms,
inammatory processes and genetic traits. While mechanical
factors are known to be necessary for the development of
osteoarthritis, it is still unclear what role the other factors
play (Hochberg et al., 2015). Osteoarthritis is known to be a
metabolically active disease, and changes can also occur within
the peripheral and central nervous systems, which may explain
non-mechanical pain symptoms described by some people with
osteoarthritis (Cruz-Almeida et al., 2013; Mease, Hanna, Frakes,
& Altman, 2011; Mills, Hübscher, O’Leary, & Moloney, 2019;
Skou et al., 2018).
In contrast to the notion that the joint is wearing out,
moderate levels of physical activity and exercise are believed
to be protective against the development of hip and knee
osteoarthritis (Bennell & Hinman, 2011; Fransen et al., 2015;
Skou et al., 2018). Normally functioning muscles have a
protective effect on joints as they distribute load across the
joint and help to maintain postural alignment (Bennell, Wrigley,
Hunt, Lim, & Hinman, 2013). Furthermore, there is a plethora
of studies demonstrating that improving muscle function with
exercise can reduce pain and improve function for people with
hip and knee osteoarthritis (Fransen et al., 2015; Hochberg et
al., 2012; Hunter & Lo, 2009; Loew et al., 2012; Skou et al.,
2018). Conversely, weak muscles at or around joints can lead
to the development of osteoarthritis due to a higher chance of
injury and altered load management (Hochberg et al., 2015).
Practice point myth 2: Osteoarthritis is not “just” joint wear and
tear. The disease is better conceptualised as a syndrome that
includes joint wear and failed repair. Hence, it is essential to
avoid describing or referring to osteoarthritis as “wear and tear”
when speaking with patients.
Myth 3: The worse the imaging looks, the worse the
joint is
Imaging, such as radiographs and magnetic resonance imaging
(MRI), is a standard tool used to diagnose osteoarthritis.
However, only half of the people with radiographic osteoarthritis
(visible x-ray changes) have clinical symptoms (Jordan et al.,
2007; Phan et al., 2005). As such, the assessment of a person’s
signs and symptoms may be more clinically relevant than the
imaging ndings. Furthermore, clinical guidelines suggest that
requesting an x-ray is not required to make the diagnosis of
osteoarthritis and is potentially problematic as it reinforces a
mechanical view of the disease (Bennell, 2013; Hunter, 2017;
McAlindon et al., 2014; National Institute for Health and Care
Excellence, 2015). In most cases, the diagnosis of hip or knee

20 | NEW ZEALAND JOURNAL OF PHYSIOTHERAPY
joint osteoarthritis can be made by considering the signs and
symptoms that a person presents with (Hochberg et al., 2015).
Imaging should only be considered when appraising a person’s
appropriateness for surgery or when ruling out other potential
pathologies.
Practice point myth 3: Consider the additional merit of imaging
carefully. Radiographic changes can correlate poorly with
symptoms and lead to unnecessary interventions. Take care
when describing imaging ndings to people with osteoarthritis.
For example, avoid using terminology such as “degeneration”
or “bone on bone” that may incite fear-avoidance behaviours or
the belief that nothing can be done to manage the symptoms of
osteoarthritis.
Myth 4: Osteoarthritis is the non-inammatory arthritis
Osteoarthritis was traditionally considered to be non-
inammatory arthritis, but the presence of inammatory
processes are now acknowledged (Berenbaum, 2013). Synovial
tissue inammation is believed to be one of the key intraarticular
processes that contributes to nociception and the subsequent
pain experience, with the inammatory changes leading to
intraarticular swelling (Felson et al., 2016). Moreover, extra-
articular structures can also become inamed and contribute
to the generation of nociceptive input (Hochberg et al., 2015).
Low-grade chronic inammation may be a consequence of
knee injury, or induced by metabolic syndrome or inammaging
(age-associated inammation), all of which are known risk
factors for the development of knee osteoarthritis (Berenbaum,
2013). Recent research has suggested a relationship between
osteoarthritis and metabolic disorders (Da Costa et al.,
2012; Mills et al., 2019). While the exact link is not yet fully
understood, a high body mass index and cardiometabolic
disease are associated with systemic inammation, and it
is this systemic inammation which is thought to inuence
osteoarthritis (Mills et al., 2019). Some researchers have argued
that metabolic-osteoarthritis should be described as a distinct
category or phenotype of osteoarthritis (Dell’Isola et al., 2016;
Deveza et al., 2017). Of note is that exercise is known to reduce
systemic inammation, which may explain why physical activity
positively affects pain and function for people with osteoarthritis
(Skou et al., 2018).
Practice point myth 4: Exercise can be benecial in reducing
inammation for people with osteoarthritis, and physiotherapists
can play a key role in prescribing exercise programmes.
Additionally, physiotherapists should consider engaging the
patient’s general practitioner for an analgesic review when
medication is considered appropriate.
Myth 5: Conservative treatments are ineffectual and only
designed to delay joint replacement surgery
Education, lifestyle and dietary changes, and exercise are the
cornerstone of management for people with osteoarthritis
(Bennell, 2013; Fransen et al., 2015; Hochberg et al., 2015;
Hunter & Lo, 2009). The focus of treatment for a person
with osteoarthritis should be on the maintenance of physical
function, modication of symptoms and limiting disease
progression (Fransen et al., 2015; Hochberg et al., 2015).
Treatment options should be employed progressively, starting
with more conservative treatments (exercise, weight loss,
education), and then progressing to pharmacological and more
invasive interventions (medication, surgery) as needed, while
incorporating patient preferences (Fransen et al., 2015; Larmer,
Reay, Aubert, & Kersten, 2014; National Institue for Health
and Care Excellence, 2015). In particular, there is abundant
high-quality evidence supporting exercise-based treatments
for people with hip and knee osteoarthritis (Bennell & Hinman,
2011; Fransen et al., 2015). Research shows that exercise
can positively inuence pain, muscle function, body weight,
cardiovascular tness, mood and disease progression (Bartholdy
et al., 2017; Bennell et al., 2014; Fransen et al., 2015; Kujala,
2009; Zhang et al., 2008), regardless of the structural changes
and symptom severity. The addition of joint mobilisation and
manipulation to exercise programmes may also be benecial
(Fitzgerald et al., 2016; Pinto et al., 2013).
Two of the biggest limitations to the efcacy of exercise-based
treatment are prescription and patient adherence. Poor exercise
prescription for people with knee osteoarthritis can result in
either overloading the affected joint, leading to increases in
pain and swelling; or more commonly, prescribed exercises
that are not challenging enough to facilitate a training effect
(Brosseau et al., 2016; Fransen et al., 2015; Hunter, 2017).
The inclusion of strategies to improve the adherence to the
prescribed exercises could boost treatment effectiveness (Bennell
et al., 2014; O’Brien, Bassett, & McNair, 2013). Physiotherapists
should consider employing strategies that assist people to begin
and sustain new behaviours that improve their osteoarthritis
(Bassett, 2015). Furthermore, as osteoarthritis is a chronic
disease, treatment should be viewed as a continuum of care;
hence, booster sessions should be considered to assist in the
maintenance of regular exercise (Brand, Ackerman, Bohensky, &
Bennell, 2013; Rosemann, Laux, Szecsenyi, & Grol, 2008).
Practice points myth 5: Exercise, education and weight loss
(where appropriate) are essential interventions for all people
with osteoarthritis, regardless of disease progression or symptom
severity. Prescribed exercises or physical activity programmes
should be collaboratively designed, should challenge the patient
and promote a training response, and should incorporate
strategies to enhance adherence. Joint mobilisation may also be
benecial if clinically indicated.
Myth 6: Discussing weight loss with people with
osteoarthritis is outside my scope of practice
Increased body weight is a known risk factor for the
development of lower limb osteoarthritis, and obesity is
commonly associated with progression of the condition
(Chapple, Nicholson, Baxter, & Abbott, 2011; Jacobs,
Vranceanu, Thompson, & Lattermann, 2018; Palazzo et
al., 2016; Silverwood et al., 2015). Furthermore, obesity is
associated with more negative treatment outcomes (Bliddal et
al., 2014). Weight loss is strongly recommended for people with
obesity and osteoarthritis, not only to decrease joint loading,
but also to counteract the inammatory effects of metabolically
active tissue (Chapple et al., 2011; Cicuttini & Wluka, 2016;
Jacobs et al., 2018; Palazzo et al., 2016; Silverwood et al.,
2015). Reducing body weight can signicantly lessen a person’s
likelihood of developing osteoarthritis. Critically, a reduction of
≥10% of body weight can lead to considerable reductions in

NEW ZEALAND JOURNAL OF PHYSIOTHERAPY | 21
pain for people who already have the disease (Atukorala et al.,
2016). While some physiotherapists may believe that discussing
weight loss with a patient is outside their scope of practice,
physiotherapists are well placed to assist people with making
lifestyle changes that will contribute to weight loss.
Practice point myth 6: Obesity is a known modiable risk factor
for osteoarthritis, and physiotherapists should provide support
to people embarking on a weight loss programme or refer
them on to the appropriate health professional, e.g. dietician or
exercise physiologist.
Myth 7: Joint replacement surgery is inevitable
Total joint replacement (TJR) continues to be a valid treatment
option for people with advanced hip and knee osteoarthritis, but
TJR surgery is not appropriate for everyone with osteoarthritis
(Gustafsson, Ekman, Ponzer, & Heikkilä, 2010; Gwynne-Jones,
Gray, Hutton, Stout, & Abbott, 2018; Parsons, Godfrey, & Jester,
2009). Disease progression differs from person to person, and
many people may never reach the point where TJR surgery is
appropriate or necessary. Chapple et al. (2011) identied that
disease progression is multifactorial, with predictive factors
including increasing age, varus knee alignment, radiographic
changes, high body mass index and the presence of the disease
at multiple joints. Additionally, not everyone benets from
joint replacement surgery, with a substantial portion of people
continuing to report long-term joint pain after surgery (Beswick,
Wylde, Gooberman-Hill, Blom, & Dieppe, 2012; Lingard, Katz,
Wright, & Sledge, 2004). Further research is needed to identify
people most likely to benet from surgical intervention (Rice et
al., 2018).
Practice point myth 7: Physiotherapists should only consider
referring a person for orthopaedic review (TJR) after the patient
has failed an appropriate exercise programme that meets best
practice clinical guidelines (Brosseau et al., 2016; Fransen et al.,
2015).
WHAT DOES THE FUTURE HOLD FOR OSTEOARTHRITIS
MANAGEMENT?
Exercise, education and weight loss are recommended in
several clinical guidelines (Larmer et al., 2014); however these
treatment options are not consistently or routinely offered to
people with osteoarthritis in primary care (Haskins, Henderson,
& Bogduk, 2014; Hunter, 2017; Runciman et al., 2012). Within
New Zealand, the general practitioner is often the rst, and
most commonly consulted health professional for osteoarthritis
(Jolly, Bassett, O’Brien, Parkinson, & Larmer, 2017). However,
a multi-faceted approach of exercise, education and lifestyle
advice is needed to provide effective, evidence-informed care for
people with osteoarthritis. There is clearly a need for a multi-
disciplinary approach.
Primary care management of osteoarthritis in New Zealand,
at present, is fragmented and episodic, and considerable
evidence-to-practice gaps exist. Calls have been made for an
osteoarthritis model of care in New Zealand, which would
provide a framework for implementing evidence-informed care
within the New Zealand primary care system (Baldwin et al.,
2017). The term “model of care” refers to an evidence-informed
framework or policy that outlines the ideal development and
delivery of principles of care within a health system. A model of
care goes one step further than clinical guidelines by not only
outlining what the care components should be, but also how to
deliver them within a particular health system (Briggs, Towler,
Speerin, & March, 2014). An osteoarthritis model of care would
incorporate chronic care principles such as multi-disciplinary
management, collaborative care planning and self-management
strategies.
In Australia, experienced physiotherapists are employed as
musculoskeletal coordinators within the New South Wales
Osteoarthritis Chronic Care Program Model of Care (Briggs et
al., 2014). These musculoskeletal coordinators perform initial
assessments of people with osteoarthritis and link these patients
to relevant health professionals within the multi-disciplinary
team as well as provide overall leadership of the programme
at each site. With expertise in exercise prescription and chronic
pain management, physiotherapists are ideally positioned to
coordinate and lead person-centred care within a New Zealand
osteoarthritis model of care (Baldwin et al., 2017); upskilling
and/or extended scope of practice roles could be required. As
an example, the New Zealand government’s Mobility Action
Programme (MAP) is supporting multi-disciplinary, community-
based teams to provide early management for people with
osteoarthritis (Ministry of Health, 2018). While the MAP
represents a positive step towards optimising osteoarthritis
management in primary care, formal policy support is needed to
upscale this programme and develop an osteoarthritis model of
care that would facilitate provision of equitable care to all New
Zealanders.
CONCLUSION
Many myths exist about osteoarthritis, and some will limit the
potential benets that people may gain from conservative
treatment. Busting these myths will lead to a better
understanding of osteoarthritis and could contribute to better
outcomes for people living with the disease. Physiotherapists
are well placed to do this through effective education of
patients and other healthcare professionals, and by leading the
implementation of best-practice care.
KEY POINTS
1. Many myths and misconceptions exist about osteoarthritis
that can have a negative impact on how it is managed and
thus outcomes.
2. As physiotherapists, we should explore osteoarthritis
beliefs of our patients to identify and clarify potential
misconceptions about the disease.
DISCLOSURES
No additional funding was obtained to support the production
of this manuscript beyond the usual academic salaries of the
authors.
The authors have no conicts of interest that merit declaration.
ADDRESS FOR CORRESPONDENCE
Dr Daniel W. O’Brien, Physiotherapy Department, School of
Clinical Sciences, Auckland University of Technology, Akoranga
Drive, Northcote, Auckland. Telephone: +64 9 921 9999 ext.
8707. Email: dobrien@aut.ac.nz

22 | NEW ZEALAND JOURNAL OF PHYSIOTHERAPY
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